MEDICAL TRANSCRIPTION SAMPLE REPORTS: Upper endoscopy and colonoscopy

Medical Transcription

Medical transcription is one of the fastest-growing profession in the country today.

Medical transcription offers excellent opportunity to housewives, ex-servicemen, graduate fresh or experienced, especially the newly passed ones. It is also a high income career for the graduates. You can even sit at your home and earn money from home feasibly through medical transcription career, and one can organize his/her own work timings and avoid travel to the works for and thus earn more than the usual office goers.

Nature of job, doctors will dictates the patients’ information, which we will receive in wave format through voice mail or dictaphone which consists of medical datas, which we have to type.

Transcription process is conversion of voice to electronic text form. As this process deals medical data documentation, so this is called medical transcription. The person who deals with medical data process is called Medical Transcriptionist.

Any person can do home based medical transcription program, those who are interested to learn, who able to grasp accents’ of dictators’ voice, who able to understand English, who able to form sentences grammatically and finally, who wants to earn money shortly from home or office.

There are many institutions that providing free home based medical transcription training through internet with their own “terms and condition” and time limits, duration. To avail home based medical transcription training you should computer laptop or desktop with UPS, phone and internet connection for communications. They would design the program accordingly where one can learn medical transcription from home.

Home based Medical transcription Training program duration may be 2 to 4 months.

After successful completion of home medical transcription training from institute based on your quality and quantity, you will be offered a home based job medical transcription immediately, and you are supposed to sign an agreement and can start medical transcription job from home and can start earning from home. Companies will provide you files through internet which has to be transcribed.

Based on your quality and quantity, remuneration will be fixed with incentives per month and remuneration will be gradually increased as your experience increases. One can start earn initially low, but gradually can increase with incentives as experience increases.

Quality - the document should be without error and should not commit error beyond the limit. Files should be submitted with minimum 90% accuracy to company by the medical transcriptionist and to the client, 99.5% accuracy after QC/QA. Quantity - a transcriptionist should be able to transcribe minimum of 350 lines per day, initially after successful training.

Main advantage of taking home based medical transcription work, one can organize their own work timings. They can reduce your traveling time 2 to 4 hours, so that can spend more time in working to earn more.

Thursday 2 August 2012

Upper endoscopy and colonoscopy

PROCEDURE: Upper endoscopy and colonoscopy.

INDICATIONS: Iron deficiency anemia.

PROCEDURE IN DETAIL: Indications, risks, benefits, alternatives, and limitations were explained to the patient. He gave an informed consent. He was then brought to the endoscopy room. Anesthesia provided sedation. Scope was advanced into esophagus, stomach, and duodenum. Third portion, second portion, and bulb was normal. Pylorus was normal. Antral gastritis was noted and biopsy was taken. On retroflexion, lesser curvature, greater curvature, fundus, and cardia were normal. Stomach insufflated very well. No abnormal folds were seen. There was a small nodule in the antrum next to the pylorus, which was biopsied. Otherwise, rest of the stomach was grossly negative. Esophagogastric junction was normal. Esophageal mucosa was normal. Procedure completed. The patient tolerated the procedure well and then I reintroduced the scope all the way down to the small bowel in order to take biopsies to rule out celiac sprue and then the procedure was completed.

PROCEDURE: Colonoscopy.

The colonoscope was advanced into the rectum all the way to the cecum and terminal ileum. Photographs were taken for documentation. Mucosa was then examined. On withdrawal. minimal liquid and pasty stool throughout the colon as much as possible was cleaned out. Small lesions or flat lesions could have been missed. The terminal ileum, the cecum, the ascending colon, transverse colon, descending colon, sigmoid colon, and rectum were examined. Retroflexion was done the rectum. Over 6 minutes was taken to evaluate the colon on withdrawal. Findings were that of grossly negative terminal ileum and grossly negative colon, small-to-moderate internal hemorrhoids. Procedure completed. The patient tolerated the procedure well.

IMPRESSION: Iron deficiency anemia. Endoscopy showed gastritis. Biopsy taken a small nodule in the antrum. Biopsy taken. Small bowel biopsy taken to rule out celiac sprue. Colonoscopy grossly negative. Terminal ileum grossly negative. Small-to-moderate internal hemorrhoids.

PLAN: The patient can be discharged home. Follow up in my office next week to review the biopsies. Check the celiac sprue workup and then we will plan small bowel series followed by capsular endoscopy.

MEDICAL TRANSCRIPTION SAMPLE REPORTS

Search This Blog

HBT